Assisted Suicide,Euthanasia, and Suicide Prevention: The Implications of the Dutch Experience

What impact would legalization of assisted suicide and euthanasia have on our ability to treat suicidal patients and to prevent suicide? Information from a study of the Dutch experience illustrates how legal sanction promotes a culture that transforms suicide into assisted suicide and euthanasia and encourages patients and doctors to see choosing death as a preferred way of dealing with serious or terminal illness. The extension of the right to euthanasia to those who are not physically ill further complicates the problem. So too does the tendency of doctors in such a culture to begin to feel that they can make decisions about ending the life of competent terminally ill patients without consulting the patient. “Normalizing” suicide as a medical option lays the groundwork for a society that turns euthanasia into a “cure” for suicidal depression.     

Suffering, sovereignty, and the purposes of God: Christian convictions and medical killing.

Despite a variety of "non-ecumenical" features in Christian arguments about suicide, assisted suicide, and euthanasia, there are obvious "ecumenical" aspects to be found in the general Christian prohibition of these practices. A fair reading of the Christian tradition requires that we acknowledge both the differences that distinguish particular perspectives and the fundamental themes that allow an identifiably Christian position to emerge in stark contrast to the secular discussion of these issues. Central to Christian interpretations of dying and death are an acknowledgment of God's sovereignty over human life, an understanding of suffering that stresses identification with Christ as the source of Christian hope, and the recognition that God's creative and redemptive purposes are generally (or always) at odds with the deliberate choice of assisted suicide or euthanasia.     

Individualism,authoritarianism, and attitudes toward assisted death: cross-cultural,cross-regional,and experimental evidence

We hypothesized that in individualistic cultures, individualism predicts positive attitudes toward assisted death, whereas authoritarianism is negatively associated with favorable views of this issue. Study 1 confirmed this hypothesis in a Polish sample (n=100). Study 2, using a German sample (n=102), found the predicted relationships for forms of assisted death that involved the individual self-determination of a terminally ill patient. In Study 3 (n=72), we found experimental evidence that priming individualistic aspects of the self-concept results in more favorable views of physician-assisted suicide. Using a representative sample (n=1158), Study 4 found that across the United States, regional levels of individualism are reflected in corresponding patterns of support for assisted suicide. The discussion focuses on assisted suicide as a cultural phenomenon and explores the implications of growing levels of individualism for public opinion and policy on assisted suicide.     

Depression in the Context of Disability and the “Right to Die”

Arguments in favor of legalized assisted suicide often center on issues of personal privacy and freedom of choice over one's body. Many disability advocates assert, however, that autonomy arguments neglect the complex sociopolitical determinants of despair for people with disabilities. Specifically, they argue that social approval of suicide for individuals with irreversible conditions is discriminatory and that relaxing restrictions on assisted suicide would jeopardize, not advance, the freedom of persons with disabilities to direct the lives they choose. This paper examines the idea promoted by some proponents of assisted suicide that it is reasonable to be depressed about one's diminished quality of life in cases of irreversible illness or disability and, therefore, such depression should not call into question the individual's competence to request assistance in dying. The concept of rational depression is defined and examined in the context of: four real-life cases involving individuals with disabilities who requested assistance in dying; a set of criteria commonly applied to decision-making to determine rationality; and research bearing on the emotional status of people with disabilities. It is concluded that although disability is associated with particular socially mediated stressors, there is no theoretical or empirical evidence to indicate that depression and its role in the right to die is dynamically different, more natural, or more reasonable for disabled people than for non-disabled people.     

Perfectionism,Stress, Daily Hassles,Hopelessness, and Suicide Potential in Depressed Psychiatric Adolescents

The current study examined dimensions of perfectionism, stress, hopelessness, and suicidality in a sample of adolescent psychiatric patients diagnosed with depression. This study evaluated the unique contribution of perfectionism in predicting suicidality after considering other predictors (i.e., hopelessness, depression) and it also examined the diathesis-stress model of perfectionism and suicide. A sample of 55 adolescents (41 females, mean age = 15.53, 25.5 % ethnic/racial minorities) who were psychiatric patients completed measures including the Child-Adolescent Perfectionism Scale, subjective and objective indices of life stress, daily hassles, depression, hopelessness, suicide ideation, prior attempts and suicide potential. In addition, other informants (i.e., adolescents’ parents) completed a diagnostic interview and an interview assessing major stressful experiences. Socially prescribed perfectionism (i.e., the perception that others require perfection of oneself) predicted concurrent levels of suicide potential and this association with suicide potential held even after controlling for the variances accounted for by depression and hopelessness. Hierarchical regression analyses provided partial support for the diathesis-stress model, that is, socially prescribed perfectionism interacted with daily hassles to predict concurrent suicide potential even after controlling for depression, hopelessness, and prior suicide attempt. Together, these findings suggest that socially prescribed perfectionism acts as a vulnerability factor that is predictive of suicide potential or risk among clinically depressed adolescents.     

The Many Faces of Physician-Assisted Suicide

Physician-assisted suicide is a complex and controversial issue that touches on standards of medical practice, the balance between individual rights and the rights of the state, and our fears of death and pain. Supporters of assisted suicide propose it as an alternative to a lingering, highly technological death, and define it as the act of a physician who prescribes a lethal dose of a medication for a terminally ill patient, with the knowledge that the patient intends to commit suicide. The recent U.S. Supreme Court ruling upheld prohibitions against assisting in a suicide, but left open the possibility that in certain specific cases assisted suicide might be constitutionally protected. The Supreme Court's refusal to extend constitutional protection to assisted suicide was done in part to insure that public debate and legislative fact-finding would continue. As stated in Justice Rehnquist's majority opinion, ...Americans are engaged in an earnest and profound debate about the morality, legality and practicality of physician-assisted suicide (Washington v. Glucksberg, 96-110—Opinion, 1997, p. 26). As researchers, policy makers, and health care providers, we have an obligation to insure that political debate and empirical research are continuing and productive, and that this issue becomes more than just an occasion to play out ideological or personal differences.     

Physician-assisted suicide and euthanasia: German Protestantism, conscience, and the limits of purely ethical reflection.

In this essay I shall describe and analyse the current debate on physician assisted suicide in contemporary German Protestant church and theology. It will be shown that the Protestant (mainly Lutheran) Church in Germany together with her Roman Catholic sister church has a specific and influential position in the public discussion: The two churches counting the majority of the population in Germany among their members tend to "organize" a social and political consensus on end-of-life questions. This cooperation is until now very successful: Speaking with one voice on end-of-life questions, the two churches function as the guardians of a moral consensus which is appreciated even by many non-believers. Behind this joint service to society the lines of the theological debate have to be ree-discovered. First it will be argued that a Protestant reading of the joint memoranda has to be based on the concept of individual conscience. The crucial questions are then: Whose conscience has the authority to decide? and: Can the physician assisted suicide be desired faithfully? Prominent in the current debate are Ulrich Eibach as a strict defender of the sanctity of life, and on the other side Walter Jens and Hans Kung, who argue for a right to physician assisted suicide under extreme conditions. I shall argue that it will be necessary to go beyond this actual controversy to the works of Gerhard Ebeling and Karl Barth for a clear and instructive account of conscience and a theological analysis of the concepts of life and suicide. On the basis of their considerations, a conscience-related approach to physician assisted suicide is developed.     

Treatment of Depression and Suicide in Older Adults

This article describes a cognitive behavior therapy (CBT) intervention for suicide prevention in older adults. Although many studies have found that CBT interventions are efficacious for reducing depressive symptoms in the elderly, researchers have yet to evaluate the efficacy of such interventions for preventing suicide or reducing suicide risk in older adults. In this article we describe a 12-session CBT protocol for reducing depression, suicide ideation, and other risk factors of late-life suicide. The following aspects of the treatment are described: assessing suicide risk, conceptualizing the problem through a cognitive behavioral framework, developing a safety plan, increasing hope and reasons for living, improving social resources, improving problem-solving skills and efficacy, improving adherence to medical regimen, and relapse prevention. In addition, we review other behavioral and cognitive strategies such as activity scheduling and cognitive restructuring that are commonly associated with CBT interventions for depression. We illustrate the application of these strategies through the use of case examples.     

Suicide survivors' mental health and grief reactions: a systematic review of controlled studies

There has been a debate over several decades whether suicide survivors experience more severe mental health consequences and grief reactions than those who have been bereaved through other causes of death. This is the first systematic review of suicide survivors' reactions compared with survivors after other modes of death. Studies were identified by searching the PsychINFO and MEDLINE databases. Forty-one studies met the eligibility criteria. A qualitative data analysis was performed. There were no significant differences between survivors of suicide and other bereaved groups regarding general mental health, depression, PTSD symptoms, anxiety, and suicidal behavior. The results regarding the overall level of grief are less clear, depending on whether general grief instruments or suicide-specific instruments are used. Considering specific grief variables, suicide survivors report higher levels of rejection, shame, stigma, need for concealing the cause of death, and blaming than all other survivor groups.     

自尊、体验回避和抑郁在自杀意念形成中的作用

使用自尊量表、接受和行动问卷、症状自评量表和贝克抑郁自评问卷对河南省某高校778名本科生和研究生进行问卷调查,探讨自尊、体验回避和抑郁在自杀意念形成中的作用。结果显示:(1)保护性因素自尊能够负向预测自杀意念。自尊水平越高,个体的自杀意念水平越低;(2)抑郁中介了风险性因素体验回避对自杀意念的影响作用。体验回避程度越高,抑郁程度越高,相应的自杀意念水平越高;(3)保护性因素自尊可以缓冲风险因素体验回避和抑郁对自杀意念的作用。保护性因素自尊能够负向预测体验回避和抑郁,既自尊水平越高,体验回避和抑郁倾向越弱。保护性因素自尊通过抑制风险性因素来缓冲其对自杀意念的作用。     

Correlations of attitudes toward physician-assisted suicide, death depression, death obsession, and trait anxiety

In a sample of 112 Kuwaiti college students, approval of physician-assisted suicide was not significantly correlated with scores on trait anxiety, death depression, or death obsession.     

Do Extenuating Circumstances Influence African American Women's Attitudes Toward Suicide?

African American women commit suicide less than other U.S. women and men, perhaps partly due to strong, anti-suicide attitudes. To see if suicide attitudes might be softened by extenuating circumstances such as terminal illness, 192 African American and European American women imagined themselves in one of four extenuating circumstances, then completed measures of suicide acceptability and religiosity. Both ethnic groups reported a greater likelihood of suicide when imagining depression, regardless of religiosity. Religiosity, but not extenuating circumstances, corresponded with negative attitudes toward suicide and physician assisted suicide. These African American and European American young women remained steadfastly against suicide, regardless of circumstance.     

Psychosocial treatment of depression and suicidality in adolescents

Depression is a common disorder among adolescents and is associated with a high risk of suicide. Suicide is the third leading cause of death among adolescents in the United States. Currently, there are only two evidence-based psychotherapies for adolescence depression: cognitive-behavioral therapy and interpersonal psychotherapy. Furthermore, psychosocial interventions that specifically target suicidal behavior in adolescents are even fewer in number than treatments for depression. This article will review the psychosocial interventions for depression and suicidality in adolescents and will describe a recently developed treatment that is under study for depressed suicidal adolescents.     

Cultural orientation, family cohesion, and family support in suicide ideation and depression among African American college students

This study extends previous research by examining the role of communalism, family cohesion, and family support in suicide ideation and depression in African American college students. Participants were 188 African American introductory psychology students (126 female, 61 male) from a historically black college. (1) Results showed that communalism, family cohesion, and family support were positively associated with each other. Higher levels of family cohesion and family support were associated with lower levels of suicide ideation and depression. Linear regression analyses showed a main effect for communalism and family support. Having strong communal values was positively related to suicide ideation and depression. Having strong family support was associated with fewer experiences of suicide ideation and depression. Stepwise regression analyses indicated that family support explained more variance in suicide ideation and depression than family cohesion. Implications of these results for future research and practice are discussed.     

Differentiating Adolescent Suicide Attempters from Ideators: Examining the Interaction between Depression Severity and Alcohol Use

Depressed mood, frequency of alcohol use, and their combination were examined to see if they differentiated nonsuicidal adolescents from those with suicidal ideation and adolescents with suicidal ideation from those who have made a suicide attempt. Hierarchical logistic regressions indicated that frequency of alcohol use did not differentiate nonsuicidal adolescents from those with current suicidal ideation, but severity of depressed mood did so. In contrast, alcohol use was a significant differentiating factor between adolescents who had attempted suicide compared to those with suicidal ideation only, with severity of depressed mood not being significant. However, there was also a significant interaction effect such that for adolescents with suicidal ideation and low levels of depression, increased frequency of alcohol use was associated with increased odds of a suicide attempt. These findings suggest that alcohol use may hasten the transition from suicidal ideation to suicide attempt in adolescents with low levels of depressed mood.     

Would we rather lose our life than lose our self? Lessons from the Dutch debate on euthanasia for patients with dementia

This article reviews the Dutch societal debate on euthanasia/assisted suicide in dementia cases, specifically Alzheimer's disease. It discusses the ethical and practical dilemmas created by euthanasia requests in advance directives and the related inconsistencies in the Dutch legal regulations regarding euthanasia/assisted suicide. After an initial focus on euthanasia in advanced dementia, the actual debate concentrates on making euthanasia/assisted suicide possible in the very early stages of dementia. A review of the few known cases of assisted suicide of people with so-called early dementia raises the question why requests for euthanasia/assisted suicide from patients in the early stage of (late onset) Alzheimer's disease are virtually non-existent. In response to this question two explanations are offered. It is concluded that, in addition to a moral discussion on the limits of anticipatory choices, there is an urgent need to develop research into the patient's perspective with regard to medical treatment and care-giving in dementia, including end-of-life care.     

Suicide survivors: psychotherapeutic implications of egocide.

Interviews with seven of ten known survivors of jumps from the Golden Gate Bridge and San Francisco-Oakland Bay Bridge revealed that all of them experienced transcendence and spiritual rebirth phenomena. The psychotherapeutic implications of these findings lie in helping depressed and suicidal individuals confront death in a symbolic and meaningful way. The issue is one of "egocide" (symbolic suicide) and aiding individuals in the rebirth process. In this way actual suicides can be prevented. When individuals experience partial "deaths" (like loss, failure, rejection, depression, suicidal states, or negative parts of their egos), there is opportunity for "rebirth" (positive transformation, creative change, growth, and significant spiritual reawakening). The therapeutic task is to help individuals differentiate between "ego death" and total death and to discover through the creative process of psychotherapy that overt suicide need not be a solution.     

The Moral Foundations of Equipoise and Its Role in International Research

This article reviews the Dutch societal debate on euthanasia/assisted suicide in dementia cases, specifically Alzheimer's disease. It discusses the ethical and practical dilemmas created by euthanasia requests in advance directives and the related inconsistencies in the Dutch legal regulations regarding euthanasia/assisted suicide. After an initial focus on euthanasia in advanced dementia, the actual debate concentrates on making euthanasia/assisted suicide possible in the very early stages of dementia. A review of the few known cases of assisted suicide of people with so-called early dementia raises the question why requests for euthanasia/assisted suicide from patients in the early stage of (late onset) Alzheimer's disease are virtually non-existent. In response to this question two explanations are offered. It is concluded that, in addition to a moral discussion on the limits of anticipatory choices, there is an urgent need to develop research into the patient's perspective with regard to medical treatment and care-giving in dementia, including end-of-life care.     

Reasons for Attempting Suicide among a Community Sample of Adolescents

The motives of suicide attempts among a community sample of 99 U.S. high school students were explored. Participants completed an in‐depth computer‐assisted self interview about their most recent attempts as well as additional psychosocial measures. Results indicated that nearly 75% of the adolescents engaged in suicide attempts for reasons other than killing themselves and that depressive symptoms and premeditation prior to the attempt were significantly associated with increased risk for engaging in the attempts with death as a clear motive. Linking motive for an attempt (death, interpersonal communication, emotion regulation) and treatment approach may improve prevention of subsequent attempts and completed suicides.